In this special series on careers in oncology, guest host Dr.
Miriam Knoll, radiation oncologist at the John Theurer Cancer
Center at Hackensack Meridian Health, interviews a wide range of
oncologists who discuss their greatest challenges and the decisions
that have shaped their careers. In this episode, we hear from Dr.
Vinay Prasad, hematologist-oncologist, author, and associate
professor of medicine at the University of California San
Francisco, and host of the podcast, Plenary Session.
(This podcast was recorded while Dr. Prasad was at the Oregon
Health & Science University School of Medicine).

TRANSCRIPT

Dr. Miriam Knoll: Welcome to the ASCO Daily News podcast. I'm
Dr. Miriam Knoll, and I'm delighted to be the Daily News guest host
for a special podcast series that explores the full spectrum of
oncology careers.

Dr. Miriam Knoll: I'm an early career radiation oncologist. And
in this series, I will bring you interviews with a wide range of
oncologists to hear about their diverse experiences, their greatest
challenges, and the unforgettable moments that have shaped and
continue to shape their careers. In today's episode, I'm so excited
to welcome my friend and colleague, Dr. Vinay Prasad, a medical
oncologist and associate professor of medicine at the Oregon Health
and Science University School of Medicine.

Dr. Miriam Knoll: He's also an author and host of the podcast,
Plenary Session. Dr. Prasad and I report no conflicts of
interest relevant to this podcast. Full disclosures relating to all
Daily News podcasts can be found in our Episode pages. Dr. Prasad,
welcome.

Dr. Vinay Prasad: Thank you so much, Miriam, for having me. It's
a pleasure to be here with you.

Dr. Miriam Knoll: Amazing. So my first question is, I wanted to
ask you when you first started off as an early career oncologists.
And actually, you still are an early career oncologist. Would that
be fair to say?

Dr. Vinay Prasad: I guess. I hope so. But I'm five years in the
job. So take it for what it is.

Dr. Miriam Knoll: I guess it depends on the exact
definition.

Dr. Vinay Prasad: Yes.

Dr. Miriam Knoll: But when you actually started in your first
year, you already had a large following on social media. And you
were very vocal then, and now, about how we should improve cancer
care and cancer research. And you're the host of the very popular
podcast, Plenary Session, which I was actually interviewing on
about a year ago.

Dr. Vinay Prasad: Yes, you were a lovely guest. Yes.

Dr. Miriam Knoll: Thank you. And so my question is, did you ever
consider then, and now, how social media could impact your early
career?

Dr. Vinay Prasad: That's a great question. I guess I would say I
didn't consider then. It has been a total surprise.

Dr. Vinay Prasad: And just to give you a little bit of
background, I started on faculty in 2015. So it's my fifth year as
a faculty member, and it's my first job out of fellowship. So
listeners will decide if that's early or mid-career.

Dr. Vinay Prasad: But I went back and I looked at it. One of the
first things I did as a faculty member was we did a paper that came
out in JAMA Internal Medicine about financial conflicts of interest
for doctors on Twitter, medical oncologists on Twitter. And in
doing that project, we kind of based it off my Twitter account at
the time. And it might surprise you to know that, at that time when
I started, I had about 1,000 followers.

Dr. Vinay Prasad: So I think that's some following, but I don't
know if that would be considered a large following. And from there
to five years later, it really has kind of grown. And it surprised
me that people are interested in the kinds of issues that I want to
discuss, which are very technical issues about drug development,
clinical trials, and medical evidence.

Dr. Vinay Prasad: And it kind of led me to think about doing
something else, reaching out to people. And that led to the
podcast, Plenary Session. And I guess I would say, the
honest reason why I started making a podcast was, because I,
myself, really enjoy listening to podcasts. I have a lengthy
commute, and I listen to all sorts of shows. And I really do like
shows that are done by technical experts, which also try to reach a
broad audience.

Dr. Vinay Prasad: So shows that you know don't dumb things down,
but also try to be accessible and engaging. And I thought that
there will be some opportunity to do that in oncology. And we've
been doing the show now for over a year, and it's been great.

Dr. Miriam Knoll: So would it be fair to say that you got
involved in social media and continued to do it, because you were
excited about it, and found it really interesting, and enjoyed
it?

Dr. Vinay Prasad: I guess, I would say, yes. It's a mix of
emotions, as you'll know from being on it. When I started, I think
being-- the reason I opened a Twitter account-- and I'm not a
social media type, and I don't have a Facebook page, and I'm not on
Instagram.

Dr. Vinay Prasad: The reason I created a Twitter account was
because somebody assigned it to me in a class. I was taking my MPH
degree. And I think I spent a year or two years just kind of being
a lurker, just kind of seeing what people are saying, and not even
checking it all that frequently.

Dr. Vinay Prasad: But I kind of got pulled out of my shell,
drawn into it a little bit, when one day a paper we had published,
I noticed a bunch of academics were discussing it. And they were a
little bit critical about some things, which I thought were an
unfair criticism. And that's kind of what pulled me out, out of the
shadows, and into the arena of the discussion on social media.

Dr. Miriam Knoll: Wow, that's a great story. Would you say that
social media has helped your career?

Dr. Vinay Prasad: That's a good question. I think it is a
double-edged sword. It has certainly helped in many ways, which is
that you're invited to give a lecture, or go talk to somebody.

Dr. Vinay Prasad: It's led to a collaboration with people with
whom I never would have worked with. We published papers. So there
are all these ways in which it connects you to this community of
oncologists. So that's all the plus side of it.

Dr. Vinay Prasad: I think the minus side of it is people think
of me as a social media person, and maybe for better or worse, they
think of me as somebody who does that kind of stuff. But that may
mean that they're likely to ignore that I do a lot of academic work
too, and published a few hundred papers, and have two peer review
books in the academic literature. And so I think it can be used as
a tool to disparage or trivialize something you're doing. And so I
think that's why it kind of cuts both ways.

Dr. Miriam Knoll: That's very interesting. I hadn't
thought about it that way. But I wonder if that's an impression
that someone who is not involved in social media would have, and
not something that someone who is involved would think.

Because I can't imagine anyone thinking that about you. But then
again, maybe that person who would think that has never been on
Twitter before, so doesn't actually know what it's about. You
know?

Dr. Vinay Prasad: I agree. I think there a lot of people who
aren't on Twitter who have misconceptions about it. But I'll just
give you one good example, which is Bob Califf, who is the former
Commissioner of the FDA, a senior cardiologist; he just wrote an
editorial in a cardiology journal critical of the Kardashians, he
calls it, which are people who have far more Twitter followers than
they have cumulative career citations.

Dr. Vinay Prasad: And I guess even though I've published a lot
of papers, I'm in that camp. Because cumulative career citations
only accrue on the order of decades, and Twitter followers come
much more rapidly. And so the whole Kardashian index, I think, is a
term that people have created to disparage and criticize the
changing power dynamics that have happened through social media.
It's a fictitious invented scale that accomplishes that goal.

Dr. Miriam Knoll: Yeah. Well, I think this is a discussion that
we should definitely continue. But I just have so many other
questions to ask you about jobs. But before we go to the next
question, I just want to make sure that you and I clarify that we
don't think that's the case, right?

Dr. Vinay Prasad: Yeah. And I think the benefits certainly
outweigh any negative ideas that someone who has no idea about
anything about social media may think about it.

Dr. Vinay Prasad: Social media, it's-- what all scientists want,
what all you know academics want, is for their ideas and the work
they're doing to reach the broadest and most receptive audience.
And this is just a tool, perhaps the most powerful tool we have,
that accomplishes that goal. And so anyone who's sort of
anti-social media I think is missing the printing press of the
modern age. And in retrospect, they're not going to do so well in
the history books.

Dr. Miriam Knoll: I could not agree more. And I think also
that some of the hesitation that people have to using it is because
their only exposure to social media is the Kardashians. So they
haven't met people like you who are sharing real data and
thought-provoking information that they can't find anywhere else.
So it's even beyond the typical printing press, because you can
share information that there's really no other platform for.

Dr. Vinay Prasad: That's a great point, yeah.

Dr. Miriam Knoll: Tell me about the process of changing
jobs and academic centers. Because, congratulations, I heard that
you're going to be switching over to UCSF. So I'd love to hear
about that transition for you.

Dr. Vinay Prasad: Oh, thank you. Yeah, I guess I'm still in the
midst of it, because I haven't finished packing my desk here, but
it's imminent. It's going to be happening in the next eight weeks
or so.

Dr. Vinay Prasad: I guess I would say that the biggest question
that faces a researcher is-- actually, let me pause. Let me
actually start by something that somebody told me. When I took my
first academic job, I had a very senior faculty member at the NCI,
where I did my fellowship, pulled me aside and say, congratulations
on your job. That's a great five-year job.

Dr. Vinay Prasad: And I said, excuse me? What do you mean, a
five-year job? And he said, think about the first academic job as--
not in everybody, but in many people-- people work in that job four
or five years, and they end up making a switch. And it won't
surprise me if you're one of those people.

Dr. Vinay Prasad: And I thought it wouldn't happen to me--
absolutely not the case. It's not going to happen to me. I didn't
see that in my future.

Dr. Vinay Prasad: But nevertheless, five years later, this
person's words rang really true. And I guess I would say that the
process of switching jobs or thinking about that has to do with you
really want-- you really reach a point where you have a clear sense
of what you want to do, what you aspire to do, and what you hope to
do in the future, what you're good at doing, and you also know what
you're not good at doing. I think that comes out in the first few
years of a job.

Dr. Vinay Prasad: And that's a time where you might think to
yourself, you want to be at a place where your goals and the
central goal of the organization or the institution are really
aligned. And you see opportunity for growth, opportunity for
collaboration, you see that what you do is going to be really
valued and respected. And so at the end of the day, what I want to
do is oncology policy work, work that aligns cancer medicine with I
think patients' best interests. I also enjoy teaching and working
with trainees. And I really felt like UCSF is a place with just
such a strong, strong history of doing all those things-- a huge
policy group, a really strong program of education, and really
strong training in epidemiology and bio statistics, which is the
department that I'm joining.

Dr. Miriam Knoll: So you shared with us what the mindset would
be for switching jobs. What about the nitty-gritty? Is it generally
someone reaches out to you, you reach out to someone else? What
advice would you have to other early career or even at any point in
someone's career? And how does that work?

Dr. Vinay Prasad: I think that's a great question. I guess I'd
say, the nitty-gritty is when you in your mind start to open your
mind up to the possibility of looking for another job. So for me, I
don't even-- my mind was not even open to that for the first 3 and
1/2, four years even.

Dr. Vinay Prasad: Then I think you start taking a look at job
post websites. You start looking on institutional websites. You
start listening to word of mouth, what different divisions or
groups are looking for. And you get wind of jobs here or there.

Dr. Vinay Prasad: And I think it's reasonable that, even if
you're not super serious about leaving, to go on some interviews.
You don't know what's out there unless you go look. And it's a long
process.

Dr. Vinay Prasad: In my case, it was like over, I don't know,
maybe about a year from-- maybe over a year-- from my first toe in
the water to actually committing to make the move. And so I think
it is kind of a slow process. But in my mind, the mental attitude
to consider it is the first step.

Dr. Vinay Prasad: And then the logistics of it is just to keep
an eye open. But nobody approached me in this particular situation.
Although, I'm aware, and I've heard, that there are people who get
approached with job offers, but that wasn't my case.

Dr. Miriam Knoll: That's really, really great advice. So thank
you for that. Can you tell us about your second book, which I've
already preordered on Amazon?

Dr. Vinay Prasad: Thanks.

Dr. Miriam Knoll: What advice can you give our listeners
about the process of writing a book and becoming a published
author?

Dr. Vinay Prasad: So you're referring to the book, called
Malignant.

Dr. Miriam Knoll: Yes, Malignant.

Dr. Vinay Prasad: And I learned a lesson from the first book,
Ending Medical Reversal, which needs a punchier title. So Malignant
is really everything I know about cancer policy in one book. I
guess, let me separate the two again-- so the process of doing the
book and the reason why you might want to write a book. So I guess,
let me take the process one.

Dr. Vinay Prasad: The process is, it's a long process to write a
book. And you'll see when you read this book, and you'll read
something in the chapter that I've written, and it says, "at the
time of this writing, 2017," and you're going to say, boy, it's
2020 now. But that's really how long the process takes. It takes
several years.

Dr. Vinay Prasad: The process of writing a book is you have to,
I think, first, have a clear idea of what you want to talk about,
what you want to write. Second, you've got to draft a proposal,
which is very different than a book itself. It's kind of a succinct
summary of what you hope to do.

Dr. Vinay Prasad: Third, you have to find an agent, which can
take on the order of years. And then the fourth thing is you have
to sell the book to a publisher, which can take on the order of
years again. And then you've got to write it, which is the most
important, but often the shortest period of time. And then you got
to edit it, and proof it, and all those sorts of steps.

Dr. Vinay Prasad: And in my case, I have a publisher that is a
peer review publisher. So this book is peer reviewed in triplicate,
which adds, just like an academic article, all that back and forth
peer review. So it's time-consuming. So that's the process of how
to do it, and it takes, I think, a long time.

Dr. Vinay Prasad: But let me talk about the reason why to do it.
I think you write a book when you have something to say that you
just can't say more succinctly. And in my case, for years we've
been working on so many different spaces that seem like they're not
interconnected.

Dr. Vinay Prasad: So we then work on financial conflict of
interest. We'd done work on how the FDA approves drugs with the use
of surrogate endpoints, the control arms of clinical trials,
crossover. We have done work on the cost of cancer drugs, and how
Medicare reimburses for it.

Dr. Vinay Prasad: And so it seems like these are projects all
across cancer medicine, but they're like intertwined braids, and
they tie together. And when you twist them all together, I think
you start to see the full story of why the system is set up the way
it is, and how so much cancer policy fails, I think, people with
cancer. And so me writing the book was a recognition that I was
never going to persuade people. I was never going to get people to
see this whole tapestry until I got all the strands and tried to
weave them together in front of you.

Dr. Vinay Prasad: And so that was why I wrote the book. And I
guess I would say, when you want to talk about writing a book, I
think you have to realize that a book is an intermediary endpoint.
It's a surrogate endpoint of itself.

Dr. Vinay Prasad: The goal of the book is so that there are
people out there who will read this, and I think it'll change the
way they see cancer medicine. That's the goal. And the book is just
a vehicle to do it.

Dr. Miriam Knoll: I cannot wait to read it. And I'm hearing you
speak, and it's echoing a conversation that you had on Plenary
Session. It was a few weeks ago. I forget which episode it was.

Dr. Miriam Knoll: But it was about careerism, and the idea that
you write papers because you have something that you want to say,
not because you want to write papers.

Dr. Vinay Prasad: Right, that's an important thing, yeah. I'm a
vocal critic of this careerism movement that I see all around
me.

Dr. Miriam Knoll: Do you think that it's a new
movement?

Dr. Vinay Prasad: I think it's been-- I guess I'm so new myself.
I don't know if it's always been there. But I think it's been
amplified in a way that is unprecedented. And it's amplified, I
think, in part-- social media, of course, a double-edged sword. It
also amplifies careerism.

Dr. Vinay Prasad: And just for your listeners' sake, let me
separate the two things. So there are the things you want to do in
life, and there is the things you do for your career. And to me,
careerism is advice about careers.

Dr. Vinay Prasad: That is, how can I give more lectures? How can
I have more followers? How can I sit on panels? How can I be a
consultant for pharmaceutical companies? How can I network? How can
I be successful?

Dr. Vinay Prasad: Those are all sort of the arbitrary brass
rings that people chase. And I think that they're all misguided.
Because the more and more you talk about how to achieve those
goals, you miss the entire purpose of the whole enterprise, which
is, what do you want to accomplish?

What issues matter to you? What topics interests you? What
skills do you uniquely bring to them?

Is your work accurate or truthful? Does your work matter? Is
this what you want to do with your life?

Those are the real questions, I think, that define our career.
You have to think, what are you passionate about, and what can you
do that others can't do? And then you just do it.

Dr. Vinay Prasad: And if along the way you get these rewards of
you give lectures, you get the invited consultancies, you get all
that stuff, so be it. But if you don't get it, you shouldn't feel
bad at all if what you're doing is what you really want to do. And
if what you're wanting to do is challenging, I think, the status
quo, then don't be surprised if you don't get it, you get some
pushback. But I think that's something worth taking on, that's
worth fighting for, if what you're doing is what you believe you
ought to do with your career and your life.

Dr. Miriam Knoll: I totally agree with you. And I think
that people who really understand that are less likely to separate
their life into their work life, and their life life, and their
personal life. Because it's all one thing.

Dr. Miriam Knoll: You do it all, all of it-- family, hobbies,
career. You do it all, because you feel strongly about it, because
that's what you want to do. So there's no reason to separate
them.

Dr. Vinay Prasad: I love the way you put that, because that's
what I'm trying to say, yeah. You feel strongly about it, and
that's why you do it. And that's what you want in a career.

Dr. Vinay Prasad: You and I, we pursued the career of medicine,
and we're really lucky to do it. Because we're some of the few
people, I think, who get to do something day in and day out that
doesn't feel like work. It feels like a joy. It feels like the
thing that you want to do, you want to get out of bed and do, and
that's a tremendous privilege in this world.

Dr. Vinay Prasad: And the more you chase the brass rings, and
the less you forget about what you want to do with the brief time
we have on this planet, I think the more you're prone to burn out,
the more you'll want to separate things. And I think recognizing
that, if you chase what you really want to do, those things will
naturally fall into place.

Dr. Miriam Knoll: And that was one of the goals of my doing this
podcast series, was to allow people that have-- people like
yourself-- who are excelling in many different ways of being an
oncologist and are passionate about it, and being able to share the
ways that being an oncologist can be fulfilling in many different
ways from each other. And it's very personal. So I want to ask you
another more personal career question, which is, what is the best
career advice that you remember that you've been given?

Dr. Vinay Prasad: I guess I would say that the best career
advice came to me from a wise man, who is a professor at University
of Chicago, Adam Cifu. And he's a kind guy, because I think he's
tweeted out a slide he calls "Career Advice," and he's put this out
on the internet for all people to see. And here's his career
advice.

Dr. Vinay Prasad: Choose the job that promises the best set of
colleagues. Choose the better job over the higher paying one. Be
honest with yourself about whether you'll be happy with the demands
of the job and the level of acuity of the patients.

Dr. Vinay Prasad: Don't trust that your new employers will
change the job they offer you to fit your desires. Early in your
career, say yes to everything. Later in your career, say no to
everything except the things you really want to do. And beware of
promotions that take you away from doing what you love. And he has
a few others.

Dr. Vinay Prasad: But the reason that really speaks to me is
that the theme of everything he's saying is that it's not about the
money. It's not about-- it's not about the title. It's not about
the promotion. It's about making sure that what you want to do and
the job you're signing up for are a good fit.

Dr. Vinay Prasad: And a lot of fit and a lot of job satisfaction
is who you surround yourself with, and what are the sort of tasks
you are facing. And I think that's the core of his career advice.
And I think it's very wise.

Dr. Miriam Knoll: What was the worst career advice you've ever
been given?

Dr. Vinay Prasad: Well, I guess I would say the worst career
advice I've been given is-- I guess it wasn't to me. It was
directed broadly. But I saw it on Twitter recently, and I ended up
writing a column in Medscape about it. And it was something like,
oncology is a small world. Don't make enemies, is the advice.

Dr. Vinay Prasad: And I guess the reason it's stuck with me was,
at first glance, I see that that is incredibly reasonable. It's a
small world. There are so few of us in oncology. We all know each
other after a period of time.

Dr. Vinay Prasad: Don't make enemies. Try to avoid conflict. But
I think the reason it really started to trouble me, the more I
thought about it, was that we are in the midst of a crisis in our
profession.

Dr. Vinay Prasad: We have more drug approvals than ever, but
more of the drugs we have that come to market are drugs that we
don't know if they make people live longer or live better. The
prices of our drugs are the most they've ever been. The dollar
amounts that expert oncologists are taking home from consulting
fees from pharmaceutical companies is the highest it's ever
been.

Dr. Vinay Prasad: The experts who are conflicted are the ones
who write the guidelines. The guidelines often recommend drugs
based on weak evidence. Those weak evidence guidelines are tied to
CMS and mandate Medicare reimburse for drugs without
negotiation.

Dr. Vinay Prasad: Many of the academic papers have flaws. Many
are ghost written. Many have medical writers. So what I want to say
is that we live in a time where the entire cancer system, in so
many ways, is misaligned towards corporate profits over the best
interests of patients. And if you really, as a junior person, enter
the field with this mantra, that above all else don't make enemies,
you're never going to do what it takes to fix this ship, to realign
the ship, to correct the serious deficiencies that plague our
patients. You're never going to be able to do what we need you to
do if you enter this thinking, I don't want to ever have anyone
dislike me. You're going to be a part of the problem, not the
solution. And so I think that's the worst advice.

Dr. Vinay Prasad: The right advice is, you're not in this
business to make friends. You're in this business to do what's best
for people. And 30 years sounds like a long time when you start
your career. But five years goes by like a flash, and 25 years will
go by like a flash too. And before it all ends, the system will
just be as entrenched and flawed as it was when you started.

Dr. Vinay Prasad: So if you don't do everything you can every
day you can, you're squandering your opportunity. And that's an
opportunity that I think when we swore that oath to be a doctor, we
swore an oath to do what's best for patients. And so I think that
that's bad advice. The right advice is, do what needs to be done,
and let people feel how they feel about it.

Dr. Miriam Knoll: And I know that we could continue
talking about this for hours and hours. And I know you have amazing
advice to give, and I really appreciate your time. So my last
question for today is, what advice do you have for trainees and
early career oncologists?

Dr. Vinay Prasad: I guess my advice would echo those last
comments, which is, you're entering oncology at one of the most
exciting times. There's a lot going on. You need to do your best to
stay up with oncology in an independent and thoughtful way.

Dr. Vinay Prasad: You've got to read papers yourself. You've got
to critically appraise them yourself. You've got to see what the
discussions are, the debates are. You've going to make your own
decisions.

Dr. Vinay Prasad: And when you see the system fail your
patients, you've got to be an advocate. You've got to speak out.
And I think we need your voice more than ever. So that's the advice
I'd leave them with, which is, it's OK to make enemies, if what
you're doing is the right thing.

Dr. Miriam Knoll: Dr. Prasad, thank you so much for this
insightful discussion. And thanks so much to our listeners, for you
guys, for joining us for this episode of the ASCO Daily News
podcast. We'd love to have your feedback, as always. So please,
drop us a line at DailyNews@ASCO.org. And of course, don't forget
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The purpose of this podcast is to educate and to inform. This is
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About the Podcast

The ASCO Daily News Podcast features oncologists discussing the latest research and therapies in their areas of expertise.